camp after school program registration form - Camp Herrlich!

CAMP WILBUR HERRLICHCAMP AFTER SCHOOL PROGRAM101 Deacon Smith Hill RoadPatterson, New York 12563Phone: (845) 878-6662 Fax: (845) 878-2030Web Page: www.campherrlich.org Email: info@campherrlich.orgREGISTRATION FORMPrior to the school year beginning, please return completed form to the above address with a non-refundable deposit of$100 (or first month’s tuition, whichever is less) which will be applied towards the first month’s tuition (checks payableto CAMP HERRLICH). During the school year, please submit this form with the first month’s tuition. Scholarship isavailable, call the office for more information! Please complete a separate form for each child registered. Once yourregistration is processed, you will receive a confirmation package containing additional information needed for the CampAfter School Program.1. CHILDName___________________________________________________ Start Date: ________________________Address___________________________________________________________________________________Town______________________State________Zip_________Home Phone_____________________________Date of Birth___________ Sex_____Grade (as of 09/10)_______ School________________________________2. PARENTS/GUARDIANSCustodial Parent or Guardian: Mother: _____ Father: _____ Both: ______ Other: _____________________Father/Guardian Name_________________________ Mother/Guardian Name___________________________Address____________________________________ Address________________________________________Town____________________St_____Zip_________ Town____________________St_____Zip____________*Home Phone_______________________________ *Home Phone___________________________________*Cell Phone________________________________ *Cell Phone_____________________________________*Emergency # (if different from cell)______________*Emergency # (if different from cell)_________________Place of Employment_________________________ Place of Employment______________________________Business Phone______________________________ Business Phone__________________________________Work Hours_________________________________ Work Hours_____________________________________E-mail Address______________________________ E-mail Address__________________________________***PLEASE IDENTIFY, NEXT TO EACH OF THE PHONE NUMBERS PROVIDED, THEORDER IN WHICH YOU WOULD LIKE US TO CALL (i.e., 1st…2nd…3rd…4th…5th…6th)***Place a check mark in the box below the day(s) of the week that you wish to send your child to theCamp After School Program.Monday Tuesday Wednesday Thursday Friday

Camp After School Program ScheduleThe Camp Wilbur Herrlich Camp After School Program will follow the Carmel Central School District calendar. Theprogram will be open for school scheduled half days at no extra cost. Each student must bring a bag lunch forscheduled half day programs. The program will not be open for snow days or any other unscheduled school closings.Program Trips and Special EventsThe program students may attend field trips to local agencies for community service, libraries, movie theaters, bowlingalley, etc. as part of the program recreational and educational goals. The cost of transportation for program trips andspecial events are included in the Camp After School Program registration fee. Students will be supervised by Camp AfterSchool Program staff at all times during trips. You will receive notification when trips and special events are planned. Ifyou choose not to have your child attend special events or trips, you must find alternative after school care.TransportationI understand that Mount Tremper Outdoor Ministries, Inc. at Camp Wilbur Herrlich will provide transportation for mychild from only George Fischer Middle School to the camp premises at school dismissal time. Pick up at Camp WilburHerrlich is the responsibility of the parent/guardian.Authorization for Pick-upUnless otherwise specified IN WRITING, both parents will be allowed to pick up their child without being placedon this authorization list. If there are any specifications about custodial rights or pickup rights, they must besubmitted IN WRITING to the office. I am giving permission for the following people to pick up my child at the end ofthe Advantage After School Program day or at any other time deemed necessary. Your child will not be allowed to gowith anyone else unless a written note is provided. This will be strictly enforced.Name Relationship Phone_____________________________ ______________________________ _______________________________________________________ ______________________________ _______________________________________________________ ______________________________ __________________________I understand my child will be expected to abide by the rules and regulations set by the Director of the Camp After School Program.If these rules and regulations are continually ignored and broken, I understand that my child could be withdrawn from the Camp AfterSchool Program. My child is permitted to participate in all scheduled program activities, off site trips and events, unless contradictedby a medical report, which I will provide.In consideration for accepting this application, I, the undersigned, intending to be legally bound for myself, my heirs, executor andadministrators, waive and release any and all rights and claims for damages I may have against any and all agents, chaperones,employees of Mount Tremper Outdoor Ministries and any other sponsors, their representatives, successors and assigns for any and allinjuries and/or damage suffered by my son or daughter in connection with this activity. My son/daughter is in suitable physicalcondition to participate in any activities specified in my application.I further understand that photographs, photographic images, videotapes and likenesses of my child may be used in connection withpublicity of the Camp After School Program, Mt. Tremper Outdoor Ministries, Inc and Camp Wilbur Herrlich. I give permission forCamp Wilbur Herrlich to transport my child from George Fischer Middle School to Camp Herrlich on scheduled program days.Parent/Guardian Name (please print)____________________________________________________________________Signature of Parent/Guardian_______________________________________________Date________________________To register your child, please fully complete this form (a separate form for each child registered) and submit withyour non refundable deposit per child to:Mount Tremper Outdoor MinistriesCamp Wilbur Herrlich101 Deacon Smith Hill RoadPatterson, New York 12563Once you have registered, you will receive a confirmation package from Camp Herrlich.If you have any questions, please feel free to call us at (845) 878-6662All major credit cards aregladly accepted. Please callour office to provide secureinformation.***Enrollment in the Camp After School Program is limited******All children will be enrolled on a first come, first serve basis***